Strength of Recommendations
Strength Strength Visual Definition
Strong
★★★★
A high level of certainty of moderate-to-
substantial benefit, harm, or cost, or a
moderate level of certainty for substantial
benefit, harm, or cost (based on a
preponderance of Level 1 or 2 evidence
with at least one Level 1 study).
Moderate
★★★★
A high level of certainty of slight-to-
moderate benefit, harm, or cost, or a
moderate level of certainty for a moderate
level of benefit, harm, or cost (based on a
preponderance of Level 2 evidence, or a
single high-quality RCT).
Weak
★★★★
A moderate level of certainty of slight
benefit, harm, or cost, or a low level of
certainty for moderate-to-substantial
benefit, harm, or cost (based on Level 2
thru 5 evidence).
Theoretical/
foundational
★★★★
A preponderance of evidence from animal
or cadaver studies, from conceptual/
theoretical models/principles, or
from basic science/bench research;
or published expert opinion in peer-
reviewed journals that supports the
recommendation.
Best Practice
★★★★
Recommended practice based on current
clinical practice norms; exceptional
situations in which validating studies have
not or cannot be performed yet there is
a clear benefit, harm, or cost; or expert
opinion.